‘A Safe Learning Environment’: Simulation-Induced Stress Literature Review

Hazel Thompson* (Corresponding Author), Craig William Brown

*Corresponding author for this work

Research output: Contribution to journalAbstractpeer-review


Simulation-based education (SBE) is often celebrated as a safe learning environment, but this usually refers to the risk posed to patients, in this literature review the psychological safety for participants and the elements of SBE that generate or reduce stress are sought. Stress and learning have a complex relationship in adult learning; however, negative stress may inhibit memory formation and so the sustainable effect of SBE learning may be jeopardized by participants experiencing unnecessary stress during SBE. It is therefore important to identify the nature and trigger for stress in SBE to optimize this resource.
Using the online database PubMed and the search terms (stress and anxiety) AND (Simulation) AND ((clinical education, medical education)) without limits on publication type or date, 20 articles were returned. A non-systematic review was undertaken. Articles that were designed to deliberately introduce stress into SMEs to gauge the effect on performance were excluded. Included studies analysed the type, characteristics and potential triggers of stress evoked through participation in SBE. 17 studies were retained.
No studies in the UK were returned, SBE participants were from undergraduate and post-graduate settings and there was a mixture of professional groups included with three studies looking at team-based SMEs. Study design and method varied with an observational study being the most common method. Only one looked at qualitative data from focus groups of SME participants. Nearly all studies recorded a physical marker of stress – heart rate, cortisol level or visible signs of stress such as shaking hands. Two studies looked at techniques to actively reduce stress within the SBE activity; a mindfulness exercise before a task-based simulation and an introduction of a period of relaxation prior to debriefing. Faculty awareness of participant stress was measured objectively in only one study. SME design and equipment stressors were directly considered in two studies.
Implications for practice:
There are limited dedicated studies addressing SBE-induced stress and how this can be modified; furthermore, a lack of research into faculty impact on stress hinders the opportunity to change. This was not a systematic literature review and so the findings are limited, but can help inform practitioners: (1) Repeated exposure and familiarity with SME reduce stress. (2) Designate roles that participants would be expected to undertake in real clinical scenarios. (3) Minimize distracting factors in the environment unless directly contributing to learning outcome. (4) Introducing a purposeful period of calm before debriefing may improve retention of learning outcomes.
Original languageEnglish
Pages (from-to)A75-A76
Number of pages2
JournalInternational Journal of Healthcare Simulation
Issue numberSupplement 1
Early online date23 Dec 2021
Publication statusPublished - 23 Dec 2021


  • Simulation
  • Stress


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